1ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, Chandigarh, India, 2ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India, 3Centre for Health Informatics, National Institute of Health and Family Welfare, New Delhi, India, 4ITS Project, KIT, Netherlands, New Delhi,India, 5ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India.

Country - ies of focus

India

Relevant to the conference tracks

Health Workforce

Summary

Skills based training of health personnel and task shifting have been two strategies under NRHM to address the shortfall of human resources in health in India. Training Management Information system, a web based “single window” software application was developed to create a nationwide database for health personnel that can be updated in real time at the training centres. The TMIS software pilot, launched in five states, helps collate individual level training information about each health personnel as well as health facility level information about the availability of trained health personnel. The TMIS facilitates monitoring and decision making for the policy makers and program managers.

What challenges does your project address and why is it of importance?

India finds itself ranked 52 of the 57 countries facing a Human Resources for Health (HRH) crisis. India’s major limitation has been in the production and distribution of human resources across multiple levels of care. As of March 2010, the overall HRH shortfalls range from 63% for specialists to 10% for allopathic doctors, and 9% for Auxiliary Nurse Midwives (ANMs), respectively.
Health curricula in the country have not kept pace with the changing dynamics of public health, health policies and demographics. The ANM and General Nursing & Midwifery (GNM) curricula have only twice been revised in the past 40 years. Current medical and nursing graduates in the country, trained in urban environments, are ill-prepared and unmotivated to practice in rural settings.
The health reforms under National Rural Health Mission (NRHM), include a focus on skills based training of existing health staff and task shifting to meet the shortfall for the health workforce. However, there are challenges in terms of identifying appropriate candidates for trainings, incomplete database on training status of health personnel, equity in professional development opportunities, rational posting of trained personnel and post training performance follow up of trained personnel.

How have you addressed these challenges? Do you see a solution?

The National Institute of Health and Family Welfare is the nodal agency for conducting, coordinating and monitoring performance of various trainings conducted under NRHM. The EU supported Institutional and Technical Support Project (ITS) is providing technical assistance for institutional capacity strengthening of the National and eight State Institutes of Health and Family Welfare (NIHFW, SIHFWs). The Ministry of Health and Family Welfare (MoHFW) identified quality assurance of trainings as one of the expected outputs under the ITS project which would strengthen the NIHFW and SIHFWs.
The Training Management Information System (TMIS) is a web based software application, developed by the ITS project, for nationwide database of skilled human resource to strengthen the public sector health delivery system. The TMIS will help to plan and manage RCH trainings under NRHM, rationalise deployment of trained personnel in different health facilities and strengthen monitoring of quality of training.
The web based TMIS software help collate individual personnel level training information as well as health facility level information about availability of trained health personnel. The TMIS software has two parts - dynamic and static. The dynamic section automates the data related to human resource, trainers, participants, training centres, health facilities and type of training. The real time trainings’ data is captured, updated and generates district, state and national level training reports. It integrates sms alerts to trainers and participants. The static section includes all the documents related to trainings like training guidelines, training manuals, course content, training calendars, circulars and other relevant online material.
TMIS addresses the problem of the re-entry of existing HR and training data collected over the years in excel format by bulk uploading the same into TMIS software. The TMIS facilitates monitoring and decision making for the policy makers and program managers at all levels. It will help to recommend corrective actions based on the analysis of the human resource skills gap.
In the long run, TMIS will facilitate tracking of the resource pool of trainers and of the trained personnel through GIS mapping facilitating monitoring, better planning and resource optimization. The report generated through the software will help in monitoring and evaluating the achievement in reaching MDGs.

How do you know whether you have made a difference?

The user training and pilot launch of TMIS has been done in five states – Odisha, Haryana, Uttar Pradesh, Karnataka and Andhra Pradesh from April to June 2013. The SIHFWs are the nodal agencies for TMIS management at the state level. In total, 443 district and state level data entry operators were trained on the use of the TMIS software, data preparation, data cleaning and online-entry. The database software built on SQL server platform (using .NET framework) using key variables such as: trainees, trainers, training courses at different levels of health system in India which is available on the NIHFW website. To date, basic human resources data of at least 77 districts from 5 pilot states has been collected by the district data entry operators and centrally uploaded on the software by the team at NIHFW. This uploading of the human resource data is a one time activity which will be followed by online real time updates on personnel trainings. Draft user manuals and technical training documents for TMIS software have been developed. A help desk has been set up centrally at NIHFW for answering queries of the state. The help desk has received on average at least 40 queries per month from 5 states in the last 3 months. The TMIS software has been demonstrated to all national program managers at MoHFW and has been modified to meet the needs of both national and state level authorities.
In the select districts which have started using TMIS, the health department is able to nominate appropriate candidates, facilitate post training placements and name based tracking of health professionals. The sms alerts to the trainers and participants before the trainings and the instant online certificate generation through TMIS has already streamlined the training process and has overcome the limitations of manual compilation of training data in the country. The detailed pilot data report on utilisation and application of TMIS will be available by December 2013 and will be presented in the conference. However, to date all the health authorities at pilot states have shown great enthusiasm and provided positive feedback about the practicability and effectiveness of this application.

Have you or the project mobilized others and if so, who, why and how?

Through the ITS project we have mobilised the resources at the NIHFW and SIHFWs for implementing the TMIS application. The existing staff at NIHFW and SIHFW have been trained as master trainers for training further district data entry operators. Two staff at NIHFW have been identified to act as a help desk for states and support the TMIS tasks of bulk uploading of human resource data. Similarly SIHFW’s nodal officers for TMIS have been identified and state data entry operators have been trained to address minor issues that the district level operators may encounter. The NIHFW and SIHFW infrastructure was leveraged for conducting trainings. With the TMIS deployed at state and district levels, the health authority would be equipped with a useful tool to manage training activities on-site. Further use of TMIS and integration with existing human resources for health database can speed up better manpower management and utilisation.

When your donor funding runs out how will your idea continue to live?

The sustainability plan for TMIS has been developed for 10 years and presented to NIHFW and MOHFW for formal approval. The TMIS sustainability plan specifically aims to: build up a TMIS team in the NIHFW to maintain a national/country wide database of skilled and trained human resources; assist decision makers and stakeholders to perform gap analysis of trained human resource in public health sector delivery system; maintain a Government to Government (G2G) web based application for monitoring and planning of skilled and trained health care providers and create a foundation (if required) to make TMIS cell at NIHFW to become a “centre of excellence” in Health Information Systems. The involvement of policy makers at the national level through regular interaction to exchange inputs into TMIS design, meeting with different program divisions, and the implementation of health facility hierarchy of established ministry level software Health Management Information System (HMIS) into TMIS indicate that TMIS is viewed as useful tool by MoHFW. The MoHFW has expressed their commitment in scaling the application to a national level after the pilots. The Steering Committee meeting, chaired by the Joint Secretaries of MoHFW responsible for training, and NRHM will be allocating financial resources from the next financial year.
Based on the request from MoHFW, ITS team visited a non ITS intervention state of Tamil Nadu to explore the integration of TMIS with existing Human Resource Management Information System. It is planned that further customisation of TMIS at national and state level may even enable the users to get routine statistics on training activities going on at each level, to generate automatic reports as well as get better overview of training needs and relevant demands at each geographic regions. The TMIS would certainly help human resource development and management in India in the long run.

1Department of International Health, Johns Hopkins University School of Public Health, Washington, United States, 2Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 3Department of International Health, Johns Hopkins University School of Public Health, Baltimore, United States.

Country - ies of focus

Uganda

Relevant to the conference tracks

Health Systems

Summary

Dual practice is widespread in developing countries, yet it is seldom accounted for in health workforce policies. A systems lens guided the development of a qualitative research design to describe how dual practice evolved and how it is currently managed in urban Uganda. We found that dual practice is deeply embedded in the Ugandan health system. In the absence of formal policies, the local, informal management and coping strategies provide learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of dual practice is essential for health workforce policy and planning in countries where this phenomenon occurs.

Background

Dual practice, when government health providers also work in the private health sector, is widespread in developing countries, particularly in settings with rapidly developing private sectors. However, it is seldom accounted for in health workforce policy and planning. Uganda has an active private sector and a high proportion of health providers working multiple jobs, particularly in the capital region. An informal, unenforced ban on dual practice in a system where high demand for patient services is constrained by low supply of health professionals creates complexity and unanticipated dynamics over time. Informal management of dual practice, or local responses to complexity, have not been previously documented and could inform health workforce policy and planning in Uganda and similar settings.

Objectives

Acknowledging that the health system is a complex adaptive system, this study applied a systems lens to describe how dual practice evolved and how this phenomenon is currently managed in urban Uganda.

Methodology

A qualitative research design, supplemented by a review of historical and policy documents was used to develop five case studies of government health facilities, capturing the perspective of both health providers and health managers through semi-structured in-depth interviews. This is one of the few studies examining both doctors and nurses’ perspectives on dual practice. Additionally, interviews with policy stakeholders allowed the exploration of dual practice from multiple angles, from government to private sector. A causal loop diagram was constructed using the qualitative data in order to illustrate the influence of various health system actors, as well as interactions and feedback.

Results

Dual practice in Uganda is rooted in the history surrounding the professionalization of medicine, the development of the private sector, and political and economic turmoil. Private practice, and dual practice, started as a privilege for African doctors seeking autonomy and professional status. Feedback from the economic decline and the deterioration of government infrastructure, transformed dual practice into a coping mechanism for health providers who did not migrate. Over time, the government’s skepticism and resistance to dual practice increased, although enforcing a ban has consistently been met with threats from providers leaving. Most respondents believed that the majority of health providers engaged in dual practice informally. Doctors and nurses enter dual practice through a variety of mechanisms – from direct recruitment, to informal networking. Internal labor markets have emerged around major facilities, where parallel institutions conduct well-funded research and service provision, usually related to infectious diseases. Informal management approaches at the facility level vary. In smaller facilities, nurses and doctors self-organize to ensure their shifts are covered. The facility in-charges’ emphasis is on performance and coverage during government hours, although those who had done dual practice in the past apply a personalized approach. In larger facilities, specialists organize their public and private activities depending on the type of service provided, at times in coordination with colleagues and supervisors.

Conclusion

The systems lens fostered an approach to capture the perspectives of multiple health system actors, historically and across various levels of the Ugandan health system. The findings confirmed that, in the absence of formal policies, health providers adopt informal approaches to coping with and managing dual practice. Health managers emphasize the government job as a primary duty, while at the same time recognizing the reality that there are advantages to dual practice, from both the individual and the societal perspectives. Doctors and nurses have each developed unique coping mechanisms. The local management and coping strategies are learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of how dual practice evolves and how it is managed in a system is essential for health workforce policy and planning.

To evaluate a decade of activities, better define the current environment and its future, the ESTHER European Alliance, an initiative based on hospital/institutional partnerships with low resources countries, requested an external, qualitative assessment. Results showed that added value of these partnerships and of the EEA were well perceived. EEA seems in line with the current development cooperation landscape, helping to tackle the health human resources crisis and adapted to face the new health challenges. Nevertheless to better contribute and improve, there was a need to better demonstrate EEA's contribution to the health system strengthening and review its strategy.

Background

The ESTHER Alliance (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau - EEA), a French initiative composed currently by 12 European member states (France, Italy, Luxembourg, Spain Germany, Austria, Belgium, Portugal, Greece, Norway, Switzerland, Ireland) and 1 observer (UK), was launched in 2002 to strengthen, through hospital partnerships, the capacities of low income countries to face the HIV/AIDS emergency and related diseases. Each ESTHER national entity is different from each other, but all signed a ministerial declaration of engagement to develop the initiative and are linked by a joint charter of principles.
In 2012 the Alliance members were active in 41 countries and involved in a wide range of training activities including collaboration with civil society organisations. As the last 10 years has seen a change in the worlds health needs and cooperation landscapes, ESTHER evolved and broadened its scope, scale and type of activities to include other health priorities that contribute to meet the Millennium Development Goals 4-5-6 and strengthen health systems to improve health outcomes.
In 2013, an external study was ordered by the Alliance to qualitatively assess the achievements and challenges faced by the EEA over its decade of existence.

Objectives

This external qualitative evaluation of the ESTHER initiative, at European and country implementation level, aimed to capture the EEA’s achievements and challenges, draw lessons and clarify the EEA position in the current, evolving, development cooperation and health landscape in order to better define its future. This work was made on request of the EEA.
It focused on identifying the added value of the institutional partnerships for health, on identifying and analyzing the added value that the Alliance brings as a European platform for development cooperation in health, identifying commonalities and challenges for Alliance member bilateral partnership programs, evaluating contributions that partners have made to Health Systems Strengthening (HSS) and presenting future option to move forward.

Methodology

Capacity Development International won the EEA international tender after each ESTHER national entity ranked the different candidate’s proposals for this qualitative evaluation.
Two investigators ran it. In all stages of the assessment they included the priority countries that have an active bilateral program (France, Germany, Spain, Italy, Norway and Ireland). Switzerland, Luxembourg, Greece and UK were involved in the first stage of this evaluation. Belgium, Portugal and Austria did not participate.
An extensive review of documents and literature provided by the EEA secretariat, the national coordinating bodies and the technical implementing partners, was performed. It was completed by an international literature review guided by key informants related to development cooperation, health partnerships, capacity development, human resources for health and health system strengthening.
The first stage of interviews focused on the ESTHER model, its achievement, its added value, the challenge and future. They reached the EEA secretariat, 10 northern governments, 13 national coordinating bodies and 2 experts working in the institutional partnerships.
Best practice demonstrating projects were selected by the interviewed national coordinating bodies to be included for the second type of interviews, which focused on the added value of hospital partnerships. Enablers, challenges, lessons learned and contribution to health system strengthening were reviewed. Nine northern implementing partners, 11 southern implementing partners and 3 southern government representatives were interviewed.
Results were analyzed at 4 different levels (added value of institutional partnerships for health, EEA level, National Secretariat level and partnership/project (case studies and lessons learned)) using the OECD/DAC framework (relevance, efficiency, effectiveness, sustainability) to draw out the main themes. Results were synthesised in the perspective of current thinking and EEA objectives and guidelines. Case studies concretely illustrated the evaluation, highlighted innovations, lessons learned and challenges in contributing to HSS.
Limitations were due to the limited time and geographical constraints. Data objective verification was beyond the scope of the study. Best practice projects were selected by the national secretariat and may be subject to bias. Descriptions were dependent on the completeness of information provided.

Results

The added value of institutional partnerships (IP) for health based on capacity building and sustainable improvement was clearly perceived. Benefits were: institutional strengthening, responsiveness to needs, ownership, long term building of trust and capacity, peer to peer multidisciplinary exchanges, solidarity, innovation, ability to fund unusual interventions for development cooperation, opportunities to learn how to manage in deprived conditions and cultural sensitivity. IP was felt to go well beyond traditional assistance which is centered on short term filling of capacity gaps and was considered to be a complement to the classical development cooperation.
If hospitals, often neglected in the development, should remain central to ESTHER, inclusion of other organizations or levels was valued.
Concerns expressed the IP potential contribution to the aid fragmentation/proliferation, unintended harms, the creation of pockets of excellence and their real capacity to strengthen the health system.
Recognition, objectification, better definition of the EEA contribution to the HSS were felt to be improved, as the conceptualization of the IP added value to the gaining of knowledge, evidence and ease and the conceptualisation of costs.
The EEA added value was recognized (networking, information sharing), but much of its potential is not fully realized (joint projects, joint working, coordination).
Political mandate and release of resources not straightforward. Weight given to EEA validation and mandate varies. Political commitment was sometimes seen as a mere weight to back-up “ESTHER”, an IP quality brand. Consequently the quest for external funds becomes vital. This would be eased by a better demonstration of the EEA added value beyond members’ programs. The ESTHER diversity, a wealthy fishpond cemented by valuable charter of principles, makes knowledge generation and joint work challenging. If key, knowledge management will have to be balanced as resources are restricted.
In the changing global health agenda ESTHER seems well adapted to address issues such as the non-communicable diseases or the horizontal and integrated approaches. By building capacity, contributing to medical education and continued professional development EEA clearly addresses the human resource crisis.
There is momentum to revisit the EEA vision, strategy and objectives to better adapt to the on-going changes in economy, health and development cooperation.

Conclusion

This qualitative study outlines that the EEA, which is based among others on institutional/hospital partnerships, capacity building, local ownership, is needs driven, has long term involvement, respects the Paris Declaration (enshrined in its shared charter of principles), is well aligned with the current thinking and best practices in development cooperation for health. It especially helps in tackling the health human resources crisis.
These principles and ESTHER multidisciplinary identity are clearly of value in the post MDG landscape. Initially focused on the HIV/AIDS crisis, a thematic which was already broadened to include the MDG4-5-6, the EEA has the potential to evolve and contribute to the new emergent health themes.
Added values of IP and of the EEA are well perceived by members, even if it is felt that there is still unveiled potential. The perceived addition of the work in partnerships over other forms of technical cooperation and of the EEA is nevertheless difficult to measure and demonstrate. Creation of enabling, inspiring environments by partnerships does not fully guarantee results. Approaches that address knowledge and capacity gaps through empowerment, leadership by the beneficiary and use of country systems are quite recent and lack rigorous evaluation material to assess their impact. Therefore, efforts should be made to develop material and evaluate processes and projects, but in a light and bearable manner. This could contribute to developing evidence on how to make a quality partnership that brings added value, a matter in which the Alliance could play a role.
Worldwide, little agreement exists on the effective strategy to strengthen the health system, one of the ultimate EEA goals. Operational research could help to clarify how partnership work can contribute to HSS at different levels. The EEA projects/programs diversity is a rich field to work on. This will require the Alliance members to better define and share a common understanding of the HSS.
This knowledge generation would serve EEA to better demonstrate its impact/contribution and increase donors and key stakeholders’ interest. Balance between operational research, monitoring/evaluation and service delivery will have to be found, especially when resources are scarce.
To take advantage of this momentum, clarification and re-definition of the Alliance strategy and structural improvement seem to be needed. A motivating challenge !

1Department of Community Health, Wits School of Public Health, Johannesburg, South Africa, 2School of Public Health, Wits School of Public Health, Johannesburg, South Africa, 3Centre for Health Policy, Wits School of Public Health, Johannesburg, South Africa.

Country - ies of focus

South Africa

Relevant to the conference tracks

Health Systems

Summary

With increasing global focus on the integration of vertical programmes within health systems, methods are needed to analyse whether general health service (horizontal) managers at district level exercise administrative authority over disease programmes (administrative integration). This study adapts "decision space" analysis to measure administrative integration of HIV programme monitoring and evaluation (M&E). The study shows that horizontal managers exercise high degrees of authority in producing HIV information but not in using it for decisions, while vertical managers use HIV information but in silos. The lack of M&E integration may undermine district health system strengthening aims.

Background

In South Africa, integration is a health sector reform priority, while several vertical programmes exist, notably for HIV, tuberculosis (TB), and maternal and child health (MCH). Historically a national HIV/AIDS directorate and specialist HIV managers have vertically managed the HIV programme and HIV programme managers account for ear-marked HIV programme funding through dedicated parallel reporting mechanisms. This is at odds with current health sector decentralisation reforms that envisage integrated management of health services under the control of generalist (horizontal) managers at a decentralised district level. National health policy envisions health districts as the foundation of the national health system.

Objectives

If health districts are to be the foundation of the health system as envisaged, then horizontal district managers would need to be allocated and to exercise authority over district health services, including disease-specific interventions (i.e. administrative integration). This study examines whether this is happening in the South African health system. We use the HIV programme as a case study given its traditionally vertical approach, and focus on the M&E (information) function as a tracer for analysing administrative integration. The research aims are to:
1. Describe the extent to which horizontal managers exercise authority over HIV M&E coordination.
2. Explore factors associated with exercised authority.

Methodology

The research explores two hypotheses: a) vertical managers exercise higher degrees of authority than horizontal managers in administering HIV M&E; and higher management capacity and HIV M&E knowledge are associated with higher degrees of exercised authority. This cross-sectional study was conducted in two of South Africa’s nine provinces. Fifty one participants were interviewed including: a) managers primarily responsible for general health services or general health information (horizontal manager) and b) those responsible for vertical services or information (vertical manager). HIV M&E was defined as the production of HIV information (HIV data collection, collation, analysis) and use of HIV information for decisions.In the absence of existing methods for measuring 'exercised authority' over vertical programmes, Bossert's decision-space’ approach provided a useful frame. Since decision-space analysis has not been applied to either the M&E function or in the context of programme integration, it was adapted to measure ‘exercised (administrative) authority’ in this study. We defined exercised authority as a manager undertakes tasks to oversee HIV data collection, collation and analysis, and uses HIV data to review the programme and take action. To measure this, we first identified the M&E tasks that managers were expected to perform within each M&E domain (collection, collation, analysis, use) and then administered a semi-structured questionnaire to collect data on participants’ performance of these tasks. We developed four sub-scales to measure the degree of exercised authority for each M&E domain. Sub-scales comprised several items (M&E tasks), which we coded ‘no’ if a respondent did not perform the task (score zero) or ‘yes’ if s/he did. We computed an ordinal dependent variable for each HIV M&E domain and coded observed scores as ‘low’, ‘medium’, and ‘high’. We performed ordinal logistic regression to explore whether explanatory variables (actor type [horizontal or vertical], health system level, highest, qualification, duration of management experience, management capacity score, and M&E knowledge score) were predictive of higher degrees of exercised authority.

Results

More than 75% of participants were female, with an undergraduate degree or higher, and had some management
training. Participant characteristics were similar between vertical and horizontal managers. Horizontal managers attained higher mean scores for HIV data collection.

Conclusion

In light of the increasing focus on health system strengthening and integration, our research makes a contribution
by providing a method and scales for measuring and monitoring administrative integration. We anticipate that
these scales will be strengthened further by empirical testing on larger samples and varied settings. In applying this
method to South Africa’s public sector HIV programme, we find that HIV M&E coordination is generally not administratively integrated, characterised by horizontal managers exercising little authority in using HIV data, and vertical managers using HIV data in sub-programme silos. We argue that this programme model potentially undermines South Africa's policy aims of integrated management of district health services under the authority of horizontal general health service managers. The research also indicates that plans for integrating the HIV programme within the health system at decentralised district level should include investments in strategies to equip horizontal managers with the knowledge and skills to use programme data for decision-making.

The mental health reform in BiH was launched in 1996 focusing on community-based care and so far has made significant progress in the development of a large network of community mental health centers. In the centers multidisciplinary teams operate, however nurses are the largest and least skilled professional category of professionals and have the highest fluctuation rate within health system. The reform project in BiH (Mental Health Project in Bosnia and Herzegovina) is focused on the informal education of nursing staff with the objective of professional development, empowering and providing networking as a first steps toward a systematic re-profiling of nurses in mental health.

What challenges does your project address and why is it of importance?

In 2008/09 the survey "Situation analysis and assessment of community-based mental health services in Bosnia-Herzegovina“ (Mental Health in SEE Project 2009) was undertaken. The findings of the 2008/09 survey were used as the baseline for the Mental Health Project in BiH to monitor changes and improvements made with the project's support. A self-assessment of the middle-level nursing staff in this survey revealed that the staff believed they were under-trained. 46% of nurses believed they had not received enough training to work in a mental health centre, and the MHC team members believed that the work of the nursing staff was not recognised by other health professionals and that there were prejudices caused by vaguely defined job descriptions for the nursing staff working in a MHC team. A new concept of nursing, as well as the empowerment of nurses within the system of community mental health, requires well trained nurses, whose knowledge is closely linked to psychological, sociological, philosophical, educational, medical and expert training. This would improve the ability of nurses to assume new tasks. This can be achieved through formal education, non-formal education, continuing professional education, as well as initiative and creativity in the field of nursing.

How have you addressed these challenges? Do you see a solution?

The adequate re-profiling of nurses in mental health is optimally achieved through formal education. This project presented informal education as the first step to a systematic aproach. Education has garnered excellent results in terms of narrowing the gap of professional training, but the benefits of education are more reflected in the development of contacts, exchange of experiences and formal networking of these professional groups that did not previously exist in the form of professional associations. The results indicate that associated advocacy for the development of nursing legislation on education and employment in mental health is required.

How do you know whether you have made a difference?

The results of the performance evaluation of the Conducted Educations suggested key improvements in the work of this professional group. 96 % of respondents felt that the education contributed to providing quality services to patients and their families through individual or team work. Particular emphasis was upon the acquisition and use of new knowledge, skills and techniques in work (88%), the rights and obligations of medical professionals and patients (66%) and combating the stigma of mentally ill patients in society (32%). 90 % of respondents observed changes in the area of respect for the professional attitudes of mental health nurses by other team members. Particular emphasis was on the experience exchanges among colleagues (65%), the level of self- confidence in the process of presenting opinions to their superiors (64%) and an additional level of competence to work within a multidisciplinary team (53%). With continous collaboration with mental health staff in MHCs there is greater viability for the initiatives taken by nurses to process their difficulties in work.

Have you or the project mobilized others and if so, who, why and how?

The key project holders and implementers were the Ministries of Health, and their key responsibility was to make the entire process a success by ensuring the participation of nursing stuff and relevant experts and key stakeholders in the implementation of activities, as well as to provide further support to the continuing education of nursing staff.

When your donor funding runs out how will your idea continue to live?

Sustainability is ensured through cooperation with other projects whose main goal is to work on legislation that would provide a legal framework for the employment of nurses in mental health, including formal education, by providing needed information and support.

1Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa, 2Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.

Country - ies of focus

South Africa

Relevant to the conference tracks

Infectious Diseases

Summary

The study presents findings from a research conducted in a refugee population in South African city known to be non-endemic to malaria transmission.

Background

It is reported that 64% of malaria cases in South Africa are imported. This is expected given the high influx of refugees into the cities and reports by United Nations High Commission for Refugees that South Africa carries the highest number of asylum seekers globally. Although South Africa has planned to eliminate malaria by 2018, current interventions and research only take place in malaria endemic areas, which are remote and rural.

Objectives

The aim of this study is to determine prevalence of malaria infection among a refugee population living in a malaria non-endemic city of KwaZulu-Natal province, South Africa.

Methodology

After obtaining relevant approvals and consent, adult refugee participants were recruited from a faith-based facility offering social services in a city of KwaZulu-Natal province. The participants were screened for malaria using rapid diagnostic tests and confirmed with microscopy. Demographic data for the participants were obtained using a closed ended questionnaire.

Results

Data were obtained for 303 participants consisting of 52% females and 48% males ranging from 19 to 64 years old. Of these 303 participants, 289 originated from different African countries, mainly central Africa. Two hundred and ninety participants provided a blood sample for screening of malaria. Of these, 3.8% tested positive for rapid diagnostic test and 5.2% for microscopy. The majority of malaria infections were due to Plasmodium falciparum.

Conclusion

The study confirms important findings that include the prevalence of asymptomatic malaria infections detected in a refugee population and residing in an urban area of KwaZulu-Natal province that is not endemic for malaria. These findings have important implications for both public health and malaria control in South Africa, particularly since the country has decided to eliminate malaria by 2018. To achieve this goal, South Africa needs to expand research, surveillance and elimination activities to include non-endemic areas and marginalized communities. The findings further emphasize the importance of integrating services such as malaria surveillance into other public health intervention programmes, and provide refugees with full access to public health services. Other implications of the findings and possible challenges threating the success of the malaria elimination process and health service provision in South Africa are discussed.

Pre-eclampsia/eclampsia is responsible for upwards of 20% of maternal morbidity and mortality in developing countries. We examine the relationship between food intake and symptoms of pre-eclampsia and eclampsia among Indian women aged 15-49 (n=39,657) for the most recent live birth in the five years preceding the National Family Health Survey-3 (2005-06). Daily consumption of milk, vegetables, chicken/meat and weekly pulses/beans consumption are associated with substantially lower risk of pre-eclampsia. Eclampsia risk is higher among those who consumed fruit and chicken/meat occasionally, and lower among those consuming vegetables daily.

Background

Pre-eclampsia and eclampsia pose significant threats to maternal health, particularly in developing countries. In low-and middle-income settings, these two conditions affect approximately 8% of all pregnancies, causing an estimated 15%-20% of maternal morbidity and mortality. Pre­eclampsia is a life threatening complication of pregnancy that typically starts after the 20th week of gestation. Women with pre-eclampsia may present with symptoms such as headache, upper abdominal pain, or visual disturbances and have raised blood pressure, ankle oedema and proteinuria. When pre-eclampsia is left untreated or is severe, giving rise to seizures/convulsions which cannot be attributed to other causes (such as epilepsy), the condition is known as eclampsia. Although several studies have found that micronutrient deficiencies, such as iron, vitamin A, vitamin C, and calcium, contribute to pre-eclampsia risks, few studies have evaluated the potential role of different food types.

Objectives

Existing nutritional evidence is highly variable. Dietary patterns may influence maternal antioxidant levels, mediating the link between pre-eclampsia and oxidative stress, an established risk factor. However, consumption of high-energy diets may increase risk of pre-eclampsia by inducing abnormal lipid metabolism, while consumption of dietary fibre may regulate these metabolic processes, thereby reducing risk. However, studies which have attempted to test these links empirically have not been conducted in high burden countries, nor have they employed appropriate multivariate models. To our knowledge, there has not been any previous large-scale report concerning the dietary risk factors for pre-eclampsia and eclampsia in Indian women. Here, we evaluate potential dietary risk factors of pre-eclampsia and eclampsia, using a large representative sample of Indian mothers in the third National Family Health Survey conducted during 2005-06.

Methodology

Data were taken from the most recent wave of the National Family Health Survey (NFHS-3, 2005–2006), India’s Demographic and Health Surveys. NFHS-3 collected demographic, socioeconomic and health information from a nationally representative probability sample of 124,385 women aged 15–49. The sample is a multistage cluster sample with an overall response rate of 98%. All states of India are represented in the sample (except the small Union Territories), covering more than 99% of the country’s population. The analysis presented here focuses on 39,657 women in the sample who report being married and who have had a live birth in the five years preceding the survey. The survey was conducted using an interviewer-administered questionnaire in the native language of the respondent. To assess the occurrence of pre-eclampsia, mothers were asked if at any time during their last pregnancy they experienced relevant symptoms, including difficulty with vision during daylight, night blindness, convulsions (not from fever), swelling of the legs, body or face, excessive fatigue, or vaginal bleeding. Women who reported difficulty with vision during daylight, swelling of the legs, body, or face, or excessive fatigue were coded as having symptoms of pre-eclampsia, whereas those who reported experiencing convulsions (not from fever) were coded as symptomatic of eclampsia. Data on blood pressure and proteinuria during pregnancy were not available in the NFHS. Dietary intake variables were based on the self-reported frequency of consumption of milk or curd, green leafy vegetables, fruits, pulses and beans, eggs, fish, chicken or meat, categorised into daily, weekly, occasionally, or never. Potential confounders and covariates were selected on the basis of previous knowledge of their association with pre-eclampsia/eclampsia. We used multiple logistic regression to estimate the association between variation in dietary intake and pre-eclampsia and eclampsia risk after adjusting for maternal factors, biological and lifestyle factors and socio-demographic characteristics of the mothers. Models were adjusted for sampling weights (IIPS & Macro International 2007). All analyses were conducted using the SPSS statistical software package Version 19.

Results

Overall 55.6% of mothers reported pre-eclampsia symptoms, and 10.3% reported eclampsia. Table 1 reports the results of our statistical models. After adjusting for maternal, biological, and chronic disease risk factors, as well as socio-demographic characteristics, we found that the risk of pre-eclampsia was significantly lower among women who consumed milk daily (OR:0.88;95%CI:0.81-0.96), green leafy vegetables daily/weekly (OR: 0.69 to 0.76), pulses or beans at least weekly/occasionally (ORs ranges from 0.84 to 0.92), fruits daily (OR:0.92), eggs weekly/occasionally, consumes fish (OR:0.90) or chicken/meat daily or occasionally, with added reference to those who never consumed them. However, a greater risk of pre-eclampsia was found among women consuming fruits weekly/occasionally (OR:1.11), eggs daily (OR:1.23) and fish weekly (OR:1.22). The risk of eclampsia was lower among those consuming green leafy vegetables (ORs ranges from 0.74 to 0.79), consuming fish weekly or occasionally (ORs ranges from 0.44 to 0.62), eggs weekly or occasionally (Ors ranges from 0.61 to 0.76), but was higher among those who consumed fruits (ORs ranges from 1.18 to 1.44), chicken/meat occasionally (OR:1.28;95%CI:1.11-1.48) with reference to those who never consumed them.

Conclusion

Our study provides empirical evidence of an association between the frequency of intake of specific food items and prevalence of pre-eclampsia/eclampsia in a large nationally representative sample of Indian women. Findings suggest that variation in the frequency of consumption of specific foods has a substantial effect on the occurrence of symptoms suggestive of pre-eclampsia/eclampsia in this population. The strengths of our study include the large nationally representative study sample and the population-level focus on the predictors of pre-eclampsia and eclampsia. However, due to the general challenges of measuring hypertensive disorders in population-based studies, the information of the symptoms of pre-eclampsia and eclampsia presented here is based on self-reports and should therefore be interpreted with care. Although we adjusted for several confounding variables, we cannot exclude the possibility of residual confounding. In these analyses, the cross-sectional design precludes causal inferences and we were limited to the questions used to elicit lifestyle and dietary information. Few population level studies exist which assess the dietary determinants of pre-eclampsia and eclampsia. This study is important because few others have reported pre-eclampsia/eclampsia prevalence rates based on population-level data. Our study implicates that modifiable risk factors for pre-eclampsia/eclampsia exists and thus there is a need for replication of findings given that the dietary patterns are modifiable. Our study findings may serve as an important call for health care providers to heighten their awareness of the increased population-level risk for pre-eclampsia and eclampsia disease originating in pregnancy. With the target of the Millennium Development Goals in sight, pre-eclampsia/eclampsia should be identified as one of the priority areas in reducing maternal mortality in India. However, further research involving the use of a more comprehensive dietary measure, pre-pregnancy assessment of all the risk factors and ascertainment of dietary intake prior to the development of pre-eclampsia and eclampsia and accuracy of reporting of the symptoms of pre-eclampsia and eclampsia are needed in a developing country setting.

In 2009, UNAIDS called for the virtual elimination of Mother to Child Transmission. In 2011, the Global Plan started and it covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV. The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files were used in monitoring the progress of these countries. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear.

Background

In 2009, the Joint United Nations Programme on HIV/VIGS (UNAIDS) called for the virtual elimination of Mother to Child Transmission, a call that has since been embraced by many agencies, regional coordinating bodies and national governments.
In 2011, at the United Nations General Assembly High Level Meeting on AIDS, global leaders made commitment with a plan towards the elimination of new HIV infections among children by 2015 and to keeping their mothers alive. This plan covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV.

Objectives

The objective of this study was to access the progress of the priority countries involved in Global Plan towards the elimination of new HIV infections in children and keeping their mothers alive.

Methodology

Research question:
What is the progress made by the priority countries towards the elimination of new HIV infections in children and keeping their mothers alive.Methods:
The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files. The study looked at the overall target 1 which is geared towards reducing the number of new HIV infections among children by 90%. The study also looked at Prong 3: Targets 3.1 - reducing mother-to-child transmission of HIV to 5% , Target 3.2 - having 90% of mothers receiving Perinatal antiretroviral therapy or prophylaxis and Target 3.3 - having 90% of breastfeeding infant-mother pairs receiving antiretroviral therapy or prophylaxis. The 2009 data serves as the baseline for this study.

Results

For the overall target 1, the countries were categorized into 3 categories with 8 countries achieving rapid decline ( > 30%), 7 countries had moderate decline (20 -30%) while 5 countries had slow or no decline (10%) The percentage difference in reduction of mother-to-child transmission rate (%) (2009-2011), 9 countries (5 - 10%) and 5 countries (90%, 50-90% and < 50% in 3, 12 and 7 countries respectively.
By 2011, the percentages of mother-infant pairs receiving antiretroviral drugs to reduce transmission during breastfeeding were >50%, 21-50% and ≤20% in 3, 6 and 11 countries respectively. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear. Notably, by 2009 Botswana had achieved some of the targets. Some of the countries did not provide adequate data for proper assessment.

Conclusion

There was some level of progress among the priority countries in different areas geared towards reaching the elimination of new HIV infections in children, however some countries are still far behind. The performance in the area of mother - infant pairs receiving antiretroviral drugs is generally not encouraging. There is need for more drastic measures in the slowly progressing countries and keeping pace with the others. This research will be published in open access journals and presented to the research communities.

CCEBDM is a pan India program for the capacity building of primary care physicians in the field of diabetes. As the country is becoming the diabetic capital with a lack of trained physicians in this field this program is launched in 2010. An evaluation was done to assess the short impact of the program and it was found that the program was effective and the skills of the physicians improved after attending the training program.

Background

Diabetes is considered one of the major contributors to the global burden of disease. It exemplifies management challenges because of long latency, chronicity, multi-organ involvement and long term care. In India, health system is constrained in term of trained manpower and limited institutional capacities for diabetes management. A balanced approach to equip primary care physicians with advanced and newer evidence based knowledge for better diabetes management is fundamental.

Objectives

This article/paper is aimed to assess the impact and effectiveness of PAN INDIA Certificate Course in Evidence Based Diabetes Management (CCEBDM).

Methodology

CCEBDM is an evidence based diabetes management course with the objective of improving the treatment outcomes for patients by serving as an evidence based guidance for clinical decision making in risk assessment, diagnosis, prognosis and management of diabetes. Improvement in knowledge of physicians was assessed by quantitative and qualitative methods. For quantitative analysis pre and post test scores were used and for qualitative analysis, end-line evaluation as a cross-sectional survey was conducted with 100 and 125 randomly selected physicians from CCEBDM Cycle-I and cycle-II respectively using pre tested scheduled questionnaires two months after completion of cycles.

Results

Pre-post test scores of 2776 physicians were assessed for the knowledge improvement and it was found that there is significant improvement (P value < 0.05) in knowledge regarding basics of diabetes, pharmacological treatment, acute and chronic complications with management. Once the course was completed the frequency of treating diabetic patient/physician/month increased (38% 501 to 1,500 patients per month and 44% stated that they treated about 101 to 500 patients per month), and the confidence level of physician increased in the field of diabetes diagnoses and management. Frequency of physicians who were confident to manage diabetic complications like hypoglycaemia (73%), peripheral neuropathy (94%), skin complication (82%), sexual dysfunction (78%), diabetic foot (74%) and nephropathy (71%) increased. 90% were confident about managing patients on insulin independently.
While assessing the clinic structure it was found that 66% of physicians had provision for laboratory facilities routine blood screenings, 53% had on-site dieticians who help the diabetic patients, 35% had a counsellor to guide the patients, 49% were using DBMS, 79% had full time nurses on duty, and 76% used various forms of Patient Education Resources to elicit awareness about diabetes. The majority of the physicians agreed that the course contributed significantly to their knowledge of diabetes management and added value to their treatment skills. All agreed that curriculum was up-to-date with latest advances and guidelines and faculty’s personal clinical experience added to their teaching were very useful as now they can consult the diabetic experts anytime for references.

Conclusion

CCEBDM is an evidence based course and uses recent clinical findings in developing clinical guidelines for better management of diabetic patients and is very effective in improving the knowledge of physicians and clinical practices in diabetes management. Also by building the capacity of primary care physicians in diabetes management, it seems to be a solution to control the increasing burden of diabetes and to improve the productivity of people who are living with diabetes.

Increasingly, there is an emphasis upon the need for scaling up the capacity of primary health care. The Primafamed-network (www.primafamed.ugent.be), at its workshop in November 2012 formulated a statement on human resources for primary health care. They formulated a plan that will lead to 30.000 new family physicians in sub-saharan Africa by 2020. There is an increasing need for skilled primary health care providers, and also family physicians at the primary health care level in Africa. Until now, in different African countries only a small number of family physicians have been trained. There is a huge problem of recruitment of family physicians in the medical faculties.

Background

Accessible and comprehensive primary health care is a key factor to solve the health problems of the developing countries, also in Africa. There is a need to scale up both quality and capacity of family medicine in the context of primary health care teams in Africa. The actual programs have only been able to train a very limited number of family physicians. Increasingly, countries and ministries of health recognised the importance of this discipline to strengthen health systems.

Objectives

To formulate a policy statement to scale up family medicine and primary health care in Africa and to develop a strategy accordingly.

Methodology

At the recent Primafamed-workshop in Vic Falls (Zimbabwe), a gathering of African representatives from 20 African countries discussed the different strategic options in order to scale up the capacity of family medicine and primary health care. The result was a statement published in the African Journal of Primary Health Care and Family Medicine (http://www.phcfm.org).

Results

Starting from reports from various countries, with a diverse scale of strategic approaches to capacity building in family medicine, a debate formulated a statement on scaling up. Important choices are related to the duration of the training, increasing the recruitment from undergraduate curriculum, and utilising appropriate educational strategies to train family physicians in the communities. Increasing exposure in undergraduate training to family and community service is essential to improve recruitment. Although some countries are in favour of a 4-years training, probably a 2-years program will be able to contribute to the achievement of the needed scaling up to capacity.

Conclusion

The participants agreed that, if the strategy could lead to the fact that 50% of the graduates would be trained in family medicine from 2013 onwards, this will lead to 30.000 new family physicians in sub-saharan Africa by 2020 in a 2-year program.